What is a competence review under the HPCA Act, and what happens in one?

A competence review is an assessment, ordered by your Council or Board under section 36 of the Health Practitioners Competence Assurance Act 2003 (the HPCA Act), of whether your practice meets the required standard of competence for your scope of practice. The authority orders one when it has reason to believe you may not meet that standard. Reviewers appointed by the authority read your records, interview you, may observe you at work and may set written or practical tasks, then report. On the report the authority can take no further action, require a competence programme, place conditions on your scope of practice or, where it finds you cannot practise safely, suspend your practising certificate. A review is not a disciplinary process and it is not a finding of misconduct. You can prepare for it, and what you do between the notice and the review day changes what the reviewers find.

When an authority orders a review

The Act gives the authority a discretion, not a duty. It can order a review of its own motion or because something has reached it: a notification from an employer under section 34 after a resignation or dismissal for reasons relating to competence, a notification from a colleague who believes you may be practising below the required standard, a referral from the Health and Disability Commissioner after a complaint, a recommendation from a Professional Conduct Committee, a conviction, a pattern in recertification audits, or a return to practice after a long absence.

Before ordering a review the authority must give you written notice of the reasons and a reasonable opportunity to make written submissions. That notice is your first chance to shape what follows. You can accept the review and ask that its scope be defined, propose a narrower review, or set out why the concern does not justify one. The guide to what happens after a notification to your Council or Board explains how the authority sorts a concern into the competence, health or conduct route, and the guide to an employer's mandatory notification covers the situation where the notice followed a resignation or dismissal.

Who decides and what they look at

The authority decides whether to order the review and what to do with the report. The reviewers assess and report. The Act leaves the method of review to the authority, so each Council and Board publishes its own description, but the elements are drawn from the same list.

• Records. A sample of your clinical records, chosen by the reviewers or drawn at random, read against the standard for your profession: the history, the examination, the reasoning, the plan, the consent, the follow-up and the handover.
• Interviews with you. Case-based discussion of your own records, questions about how you manage particular presentations, and questions about the concern that triggered the review.
• Interviews with others. Colleagues, a supervisor, an employer or a practice manager may be asked about your work. The reviewers may also seek feedback from patients where the authority's process provides for it.
• Observation. Direct observation of consultations or procedures at your workplace or in a simulated setting.
• Written or practical assessment. A written paper, a structured clinical assessment or a skills test against the competencies for your scope of practice.
• Your own account. What you say about the concern, what you have changed since, and the evidence you bring of supervision, audit and courses completed.

The reviewers measure you against the competencies and standards your authority has published for your scope: for doctors the Medical Council's statements and Good medical practice, for nurses the competencies for the scope of practice and the Code of Conduct, and so on for each profession. The guides to the Medical Council's performance assessment and to a Nursing Council competence review describe how two authorities run theirs.

What happens step by step

1. Notice of a proposed review. The authority writes with its reasons and invites your submissions by a date. Take advice before you reply.
2. The order and its scope. The authority considers your submissions and either closes the matter or orders the review, naming what will be reviewed and how. At this point it also decides whether any interim conditions are needed.
3. Preparation and the review itself. You supply records and a self-assessment if asked. The reviewers visit, interview, observe and assess over one or more days.
4. The reviewers' report. The report sets out what the reviewers found against each competency and recommends whether your practice meets the required standard.
5. Your comments on the report. You receive the report and have a stated time to respond to its findings in writing. This is where evidence of what you have already done since the notice belongs.
6. The authority's decision. The authority decides whether you meet the standard and, if not, which orders to make.
7. Completion and sign-off. If a competence programme or conditions are ordered, you complete them, the evidence is checked and the conditions are lifted from your practising certificate and the register.

Interim orders during a review

The Act allows the authority to suspend your practising certificate, or place conditions on it, while a review is pending or in progress. The test is whether the authority believes you may pose a risk of serious harm to the public by practising below the required standard. The authority must give you notice of what it proposes and a reasonable opportunity to make written submissions and be heard before it decides. A practitioner who arrives at that hearing with supervision already arranged, a narrowed scope already in place and a plan in writing gives the authority a less restrictive option to choose. The guide to interim suspension and interim conditions sets out the test and how an order is lifted.

How to prepare

• Take advice before you write anything. Your indemnity insurer, your professional association or union, or a lawyer should see your submissions on the notice and your comments on the report. For doctors that is the Medical Protection Society, for nurses NZNO, for midwives NZCOM.
• Read the competencies for your scope. The reviewers will use them as headings. Read your own records against the same headings and write down, honestly, where they fall short.
• Audit your records now. A self-audit of a sample of your notes, with the gaps named and the changes you have made since, is evidence the reviewers can test and the authority can weigh.
• Arrange supervision or peer review. A named colleague who reviews cases with you on a fixed schedule, with a short written log, shows the authority that the concern is already being managed.
• Complete courses that match the concern, and keep the certificates. A dated certificate is a fact the reviewers can record. Courses on documentation, clinical competence and reflection match the headings a review uses.
• Prepare for the interviews. Be ready to talk through your own cases: why you did what you did, what the alternatives were, what you would do now. Do not argue with the reviewers; answer the question and say what you have changed.
• Write your comments on the report with care. Accept what is accurate, correct what is wrong with reference to the records, and attach the evidence of remediation. The guide to showing insight and building a remediation plan explains what the authority reads as insight.

The outcomes

After considering the report and your comments, the authority can make any of the following orders under the competence provisions of the Act.

• No further action. The authority is satisfied that you meet the required standard, or that the shortfall has been addressed.
• Counselling or advice. A meeting or letter about the standard expected, without conditions.
• A competence programme. A set of requirements written for you: supervised practice, assessment against the competencies, mentoring, an examination, an audit or courses, with an end date and a method of sign-off.
• Conditions on your scope of practice. A limit on what you may do or where, a supervision requirement, or a requirement to report to the authority. Conditions are entered on the public register.
• Suspension. Where the authority considers you are unable to practise safely, it can suspend your practising certificate until the shortfall is remedied.
• Referral to another route. If the review reveals a health concern it goes to the health process; if it reveals conduct, a Professional Conduct Committee can be appointed.

A good outcome is a report that records a shortfall you have already named, remediation already under way, and an authority that can close the file or make a short, defined programme rather than open-ended conditions. The reviewers write down what they see on the day; the authority weighs what you have done since the notice.

Where remediation fits

Remediation belongs at three points: your submissions on the notice, your comments on the report, and the sign-off of any programme. At each point the authority asks for evidence, and a dated certificate is evidence. Ensuring Clinical Competence and Patient Safety covers the competencies a review measures and how to keep practice within them. Documentation for Healthcare Professionals covers the records the reviewers read first. Reflection for Fitness to Practise covers the written reflection that goes with your comments on the report.

Each course is NZ$200, takes 2 CPD hours, is self-paced with immediate access, and ends with a dated certificate issued by Healthcare Ethics Courses that you can submit to your Council or Board or put in your remediation plan. The remediation courses for every Council and Board are on the hub page, and the Council and Board investigation process explained shows where the review sits among the other routes.

Sources and further reading

• Health Practitioners Competence Assurance Act 2003: the competence provisions, including section 36 (review of competence) and the orders that can follow a review.
• Medical Council of New Zealand: the Council's description of its competence and performance assessment process.
• Nursing Council of New Zealand: the Council's competence review and competence programme pages.

Frequently asked questions

Can I refuse a competence review?

No. Once the authority has given you notice, considered your submissions and ordered the review, you are required to take part. A practitioner who does not cooperate with a review can have conditions placed on their practising certificate or be suspended until they do. What you can do is make submissions before the order is made, ask for the scope of the review to be defined, and ask that the reviewers see the records and the practice setting that give a fair picture of your work.

Who carries out a competence review?

Reviewers appointed by the authority. The Act leaves the method to the authority, and each Council or Board describes its own approach: a panel that includes practitioners from your profession, in some cases from your area of practice, and a lay member. They act for the authority, not for you and not for the notifier. Their report goes to the authority, and you are given a copy and an opportunity to comment on it before the authority decides what orders, if any, to make.

Will my patients or employer be told about the review?

A review is not published. Your employer will be involved if the review takes place at your workplace, if the reviewers interview colleagues or observe your practice there, or if the authority places interim conditions on your practising certificate that affect your work. Conditions on your scope of practice and any suspension appear on the public register. Patients are not told about the review unless a condition requires you to tell them, for example a supervision condition that affects how you see them.

Can I keep practising during a competence review?

The Act allows it, with or without interim conditions. The authority can suspend your practising certificate or impose interim conditions while the review runs only where it believes you may pose a risk of serious harm to the public by practising below the required standard, and only after you have had a reasonable opportunity to be heard. If the authority is considering an interim order, propose supervision or a narrowed scope yourself, with evidence, before the decision is made.

What is a competence programme?

A competence programme is one of the orders the authority can make after a review. It is a set of requirements the authority writes for you: supervised practice, assessment against the competencies for your scope, a period of mentoring, an examination, an audit of your records, or courses on the areas the review identified. It has an end date and a method of sign-off. Completing it well, with dated evidence, is how the review closes and how conditions on your practising certificate are removed.